Provider Demographics
NPI:1659885721
Name:KANE, MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KANE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 N ORIOLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3830
Mailing Address - Country:US
Mailing Address - Phone:773-351-6888
Mailing Address - Fax:
Practice Address - Street 1:1901 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5090
Practice Address - Country:US
Practice Address - Phone:773-472-0560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008072225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant